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An additional criterion has been proposed to order telmisartan 80mg free shipping hypertension 40 mg include a cluster of fewer than 200 cells in a single histological cross-section telmisartan 80 mg on-line heart arrhythmia 4 year old. Isolated tumour cells found in bone marrow with morphological techniques are classified according to discount 80mg telmisartan amex blood pressure medication drowsiness the scheme for N purchase 80mg telmisartan amex blood pressure young age. Special systems of grading are recommended for tumours of breast, corpus uteri, prostate, and liver. Although they do not affect the stage grouping, they indicate cases needing separate analysis. The suffix m, in parentheses, is used to indicate the presence of multiple primary tumours at a single site. Recurrent tumours, when classified after a disease-free interval, are identified by the prefix r. Pn Perineural Invasion PnX Perineural invasion cannot be assessed Pn0 No perineural invasion Pn1 Perineural invasion [pict] 18 Introduction C-Factor the C-factor, or certainty factor, reflects the validity of classification according to the diagnostic methods employed. They can be supplemented by the R classification, which deals with tumour status after treatment. It reflects the effects of therapy, influences further therapeutic procedures and is a strong predictor of prognosis. For purposes of tabu lation and analysis it is useful to condense these cat egories into stage groups. The stage adopted is such as to ensure, as far as possible, that each group is more or less homogeneous in respect of survival, and that the survival rates of these groups for each cancer site are distinctive. For pathological stage groups, if sufficient tissue has been removed for pathological examination to evaluate the highest T and N categories, M1 may be either clinical (cM1) or pathological (pM1). However, if only a distant metastasis has had microscopic con firmation, the classification is pathological (pM1) and the stage is pathological. Some have been incorporated into stage grouping, as has grade in soft tissue sarcoma and age in thyroid cancer. In the newly revised classifications for oesophagus and pros tate carcinomas, stage grouping has been maintained as defining the anatomical extent of disease and new prognostic groupings that incorporate other prognos tic factors have been proposed. Site Summary As an aide-memoir or as a means of reference, a simple summary of the chief points that distinguish the most important categories is added at the end of each site. These abridged definitions are not completely adequate, and the full definitions should always be consulted. This has resulted in the International Histological Classification of Tumours, which contains, in an illustrated multivol ume series, definitions of tumour types and a proposed nomenclature. Distant Metastasis the definitions of the M categories for all head and neck sites are the same. The following are the procedures for assessing T, N, and M categories: T categories Physical examination and imaging N categories Physical examination and imaging M categories Physical examination and imaging Anatomical Sites and Subsites Lip (C00) 1. Tongue (i) Dorsal surface and lateral borders anterior to vallate papillae (anterior two-thirds) (C02. Floor of mouth (C04) Regional Lymph Nodes the regional lymph nodes are the cervical nodes. Histological examination of a radical or modified radical neck dissection specimen will ordinarily include 10 or more lymph nodes. If the lymph nodes are negative, but the number ordinarily examined is not met, classify as pN0. When size is a criterion for pN classification, measurement is made of the metastasis, not of the entire lymph node. The following are the procedures for assessing T, N, and M categories: T categories Physical examination, endoscopy, and imaging N categories Physical examination and imaging M categories Physical examination and imaging Anatomical Sites and Subsites Oropharynx (C01, C05. Anterior wall (glosso-epiglottic area) (i) Base of tongue (posterior to the vallate papillae or posterior third) (C01) (ii) Vallecula (C10. Postero-superior wall: extends from the level of the junction of the hard and soft palates to the base of the skull (C11. It is bounded laterally by the thyroid cartilage and medially by the hypopharyngeal surface of the aryepiglottic fold (C13. The supraclavicular fossa (relevant to classifying nasopharyngeal carcinoma) is the triangular region defined by three points: 1. Nasopharynx T1 Tumour confined to nasopharynx, or extends to oropharynx and/or nasal cavity T2 Tumour with parapharyngeal extension* T3 Tumour invades bony structures of skull base and/or paranasal sinuses T4 Tumour with intracranial extension and/or involvement of cranial nerves, hypopharynx, orbit, or with extension to the infratemporal fossa/masticator space Note: *Parapharyngeal extension denotes postero-lateral infil tration of tumour. Hypopharynx T1 Tumour limited to one subsite of hypopharynx (see page 31) and/or 2cm or less in greatest dimension T2 Tumour invades more than one subsite of hypopharynx or an adjacent site, or measures more than 2 cm but not more than 4 cm in great est dimension, without fixation of hemilarynx T3 Tumour more than 4cm in greatest dimension, or with fixation of hemilarynx or extension to oesophagus T4a Tumour invades any of the following: thyroid/ cricoid cartilage, hyoid bone, thyroid gland, oesophagus, central compartment soft tissue* [pict][pict] 34 Head and Neck Tumours T4b Tumour invades prevertebral fascia, encases carotid artery, or invades mediastinal structures Note: *Central compartment soft tissue includes prelaryngeal strap muscles and subcutaneous fat. Histological examination of a radi cal or modified radical neck dissection specimen will ordinarily include 10 or more lymph nodes. If the lymph nodes are negative, but the number ordinarily examined is not met, classify as pN0. When size is a criterion for pN classification, measurement is made of the metastasis, not of the entire lymph node. The following are the procedures for assessing T, N, and M categories: T categories Physical examination, laryngoscopy, and imaging N categories Physical examination and imaging M categories Physical examination and imaging Anatomical Sites and Subsites 1. Histological examination of a radical or modified radical neck dissection [pict][pict][pict][pict] Larynx 43 specimen will ordinarily include 10 or more lymph nodes. If the lymph nodes are negative, but the number ordinarily examined is not met, classify as pN0. When size is a criterion for pN classification, measurement is made of the metastasis, not of the entire lymph node. The following are the procedures for assessing T, N, and M categories: T categories Physical examination and imaging N categories Physical examination and imaging M categories Physical examination and imaging Anatomical Sites and Subsites?

There are many other proposed intervals: Patil and Kulkarni list and evaluate 19 different sugges tions from the literature! discount 20mg telmisartan with mastercard blood pressure medication olmetec. The exact intervals can be overly broad for very small values of k order telmisartan 20mg hypertension heart failure, many of the other approaches try to 20 mg telmisartan otc hypertension 99791 shrink the lengths discount 80mg telmisartan otc blood pressure top number low, with varying success. If both k and time are single values the result is a vector of length 2 containing the lower an upper limits. If k is a matrix or array, the result will be an array with one more dimension; in this case the dimensions and dimnames (if any) of k are preserved. An Introduction to Probability Theory and its Applications, Volume 1, Chapter 6, Wiley. See Also ppois, qpois Examples cipoisson(4) # 95\% confidence limit # lower upper # 1. The default is to use the exact conditional likelihood, a commonly used approximate conditional likelihood is provided for compatibility with older software. Proving this is a nice homework exercise for a PhD statistics class; not too hard, but the fact that it is true is surprising. When a well tested Cox model routine is available many packages use this trick rather than writing a new software routine from scratch, and this is what the clogit routine does. The clogit routine creates the necessary dummy variable of times (all 1) and the strata, then calls coxph. If a particular strata had say 10 events out of 20 subjects we have to add up a denominator that involves all possible ways of choosing 10 out of 20, which is 20! Gail et al describe a fast recursion method which partly ameliorates this; it was incorporated into version 2. The computation remains infeasible for very large groups of ties, say 100 ties out of 500 subjects, and may even lead to integer over? Most of the time conditional logistic modeling is applied data with 1 case + k controls per set, in which case all of the approximations for ties lead to exactly the same result. The approximate option maps to the Breslow approximation for the Cox model, for historical reasons. Case weights are not allowed when the exact option is used, as the likelihood is not de? For instance if there are two deaths in a strata, one with weight=1 and one with weight=2, should the likelihood calculation consider all subsets of size 2 or all subsets of size 3? Likelihood calculations for matched case-control studies and survival studies with tied death times. Author(s) Thomas Lumley 22 cluster See Also strata,coxph,glm Examples ## Not run: clogit(case ~ spontaneous + induced + strata(stratum), data=infert) # A multinomial response recoded to use clogit # the revised data set has one copy per possible outcome level, with new # variable tocc = target occupation for this copy, and case = whether # that is the actual outcome for each subject. A version of the data with less follow-up time was used in the paper by Lin (1994). Surgical adjuvant therapy of large-bowel carcinoma: An evaluation of levamisole and the combination of levamisole and? The formula should be of the form y ~x or y ~ x + strata(z) with a single numeric or survival response and a single predictor. Counts of concordant, discordant and tied pairs are computed separately per stratum, and then added. For the coxph and survreg methods this issue will have already been addressed in the parent routine, so should not be revisited. Details At each event time, compute the rank of the subject who had the event as compared to all others with a longer survival, where the rank is value between 0 and 1. The concordance is a weighted mean of these values, determined by the timewt option. For uncensored data each unique response value is compared to all those which are larger. When the number of strata is very large, such as in a conditional logistic regression for instance (clogit function), a much faster computation is available when the individual strata results are not retained. In the more general case the keepstrata = 10 default simply keeps the printout man agable. If there are multiple models it contains the estimtated variance/covariance matrix. It is not meant to be called by users, but is available for other packages to use. Input arguments, for instance, are assumed to all be the correct length and type, and missing values are not allowed: the calling routine is responsible for these things. Value a list containing the results Author(s) Terry Therneau See Also concordance 28 cox. For a factor variable with k levels, for instance, this would lead to a k-1 degree of freedom test. The plot for such variables will be a single curve evaluating the linear predictor over time. The table component provides the results of a formal score test for slope=0, a linear? Random effects terms such a frailty or random effects in a coxme model are not checked for proportional hazards, rather they are treated as a? If the model contains strata by covariate interactions, then the y matrix may contain structural zeros, i. Columns of the matrix contain a score test of for addition of the time dependent term, the degrees of freedom, and the two-sided p-value. There will be one column per term or per variable (depending on the terms option above), and one row per event. Therneau (1994), Proportional hazards tests and diagnostics based on weighted residuals.

Women with an excess 13?23 kg of body weight have an associated 3 to 80 mg telmisartan overnight delivery hyperextension knee 5-fold greater risk of Treatment developing endometrial cancer compared with the gen T erapeutic Goals eral population purchase telmisartan 40mg on-line arteria carpals. Obesity is associated with a higher per Early stage endometrial cancer can be cured with timely and aggressive treatment involving surgery purchase telmisartan 80mg visa arteria hepatica propia, centage of adipose tissue generic telmisartan 80 mg otc hypertension 3rd stage, which is where the conver chemotherapy, and/or radiation. T erapeutic goals in sion of androgens to estrogens occurs through several recurrent and metastatic cancer are to alleviate symp pathways including the aromatization of androstene toms and decrease disease progression. The net result is increased estrogen ment of stable disease is ofen considered a reasonable exposure that results in an increased risk of endometrial therapeutic goal for recurrent gynecologic cancers. The combina Surgery is the primary treatment for early stage endo tion of paclitaxel, doxorubicin, and cisplatin for frst-line metrial cancer. This should include a thorough patho treatment of advanced endometrial cancer did improve logic assessment of the depth of myometrial invasion in progression-free and overall survival, but the toxicity relation to the overall myometrial thickness, tumor size associated with this regimen has limited its clinical use. Single-agent regi Radiation alone is a treatment option to consider in mens include gemcitabine, doxorubicin, cisplatin, car patients who are medically inoperable because opera boplatin, topotecan, and paclitaxel (Table 1-1). Morbid obesity and severe cardiopul taxel/carboplatin, gemcitabine/cisplatin, and gem monary disease are the most common reasons a patient citabine/carboplatin have demonstrated an improve with endometrial carcinoma is deemed medically inop ment in progression-free survival. More ofen, radiation is an adjuvant to either cristine have moderate activity but also signifcant tox surgery or chemotherapy. Afer surgery, patients may icities, so these agents are used primarily for sarcoma receive internal radiation therapy (brachytherapy) in tous and endometrioid histologies. In recent based upon the hormone receptor expression of the clinical trials, the use of adjuvant radiation in patients tumor. Megestrol acetate or patients with high-grade tumor and increased depth of medroxyprogesterone can be used for recurrent endo tumor invasion in the myometrium, lymphovascular metrial cancer. Patients should receive the lowest efec space invasion, large tumor volume, and involvement of tive dosage of hormonal agent to limit toxicity. Although the addi of tamoxifen and aromatase inhibitors has been limited tion of radiation does not improve overall survival, it because of low response rates (9% to 14%) and an esti reduces the risk of recurrence by 50%. Lutein treat depends on whether patients have any of the risk factors associated with disease discussed above and izing hormone?releasing hormone and gonadotropin patient factors such as age, body weight (obesity), and releasing hormone receptors are present in endometrial comorbidities. Finally, most recurrences of endometrial cancer tissue and have the ability to indirectly inhibit cancer are within the vaginal vault and may be treated estrogen pathway (negative feedback), but the overall with salvage external beam radiation with or without response rates have not been impressive (see Table 1-1). Prevention Drug T erapy Some lifestyle choices ofer a protective mechanism Until recently, chemotherapy has not played a role in and lower the risk of developing endometrial cancer. Although First, timely and proper medical treatment should be clinical trials have demonstrated improved rates of sought for precursor disorders of the endometrium to complete response and progression-free survival and decrease the opportunity for progression to endome new regimens are beginning to emerge, most of the cur trial cancer. Women should avoid the use of unopposed rent regimens have been established through clinical estrogens in the presence of an intact uterus, and all practice experience. Cau without cisplatin has demonstrated an increased overall tion is also recommended with the use of phytoestro response rate and progression-free survival for patients gens because their long-term safety is unknown. Unfortunately, chemotherapy appropriate diet and exercise interventions are impor has had no impact on overall survival in patients with tant to decrease the risk of obesity. This allows for persistent infec Because the Pap smear is an efective screening tool tions, which can lead to the development of precancerous for cervical cancer, most cases of cervical cancer are and cancerous lesions in susceptible patients. For early contributing risk factor for cervical cancer is the use of signs such as atypical cells or mild dysplasia, the recom tobacco products. Nicotine and its active metabolite, mended follow-up is a repeat Pap smear within 6 months. When cervical cancer is con cotinine have been detected in cervical mucus, confrm frmed in biopsy samples, additional diagnostic tests are ing that these and other carcinogens present in tobacco required. These car tron emission tomography) to evaluate the extent of dis cinogens are associated with induction of cellular and ease. Screening Treatment The introduction of the Papanicolaou test (Pap smear) T erapeutic Goals into clinical practice and the improvement in access to Early stage cervical cancer can be cured with timely and adherence with cervical cancer screening guide surgery. Recurrent and metastatic cervical cancer does lines have been associated with a 74% reduction in the not respond well to chemotherapy; the primary goal incidence of cervical cancer. Screening for cervical can of treatment is palliation of symptoms and controlling cer should begin about 3 years afer the onset of vaginal tumor growth and progression. Screening considered a reasonable therapeutic goal for any recur consists of an annual Pap smear and pelvic examination. Recent updates to the American Congress of Obstet rics and Gynecology screening guidelines recommend Surgery and Radiation T erapy that when a woman between 21 and 30 years old with Surgery is reserved for early stage cervical cancer. Surgery includes a hysterectomy (simple or radical) once every 2 years, at the discretion of her gynecologist. A radical trachelectomy is most successful approach for prevention is abstinence a more complicated procedure than a hysterectomy and from any sexual activity; however, this is unrealistic to requires a skilled surgeon for a successful outcome. Mutual monogamy and con When there is an isolated recurrence within a previ doms are less efective for preventing cervical cancer. Each additional partner adds another 25% to the potential risk of microscopic invasion. As a result, unlike other gynecologic cancers, 18 titers in patients treated with the vaccine increased ini the substitution of carboplatin for cisplatin to decrease tially but were at concentrations similar to the geometric toxicity is not well accepted or recommended. Use of titers in the placebo group by 36 months afer vaccina chemotherapy alone is reserved for recurrences within tion. The three-shot series must be completed within the the radiation feld or where the desired outcome is the 6-month time frame for an adequate geometric titer to be relief of symptoms.

Lancet Oncol conventional fractionation in oropharyngeal carcinoma: final analysis of 2012;13:145-153 buy telmisartan 40mg without a prescription blood pressure 60100. French Head and Neck Oncology and Radiotherapy Group randomized trial comparing radiotherapy alone with concomitant radiochemotherapy 119 purchase 20 mg telmisartan visa heart attack diagnosis. Factors associated with severe late toxicity after concurrent chemoradiation for locally advanced 122 buy 40 mg telmisartan otc pulse pressure 42. J Clin Oncol 2008;26:3582 irradiation with or without concurrent chemotherapy for locally advanced 3589 order telmisartan 80mg visa peripheral neuropathy. American Society of Radiation Oncology recommendations for documenting intensity-modulated 124. Int J Radiat Oncol Biol Phys of two radiation-cisplatin regimens for head and neck carcinomas 2009;74:1311-1318. Intensity-modulated radiation therapy reduces late salivary toxicity without compromising tumor 140. A double-blind, randomized, boost delivery methods on target coverage and normal-tissue sparing. The impact of dose on parotid salivary recovery in head and neck cancer patients treated 142. Intensity-modulated radiotherapy reduces radiation-induced morbidity and improves health 143. Intensity modulating and other radiation related quality of life: results of a nonrandomized prospective study therapy devices for dose painting. Simultaneous integrated boost intensity-modulated radiotherapy for locally advanced 137. Available at: radiotherapy for early-stage nasopharyngeal carcinoma: initial report on. Available at: in the United States: first comprehensive report of the Longitudinal. Available at: in the use of intensity-modulated radiotherapy for head and neck cancer. A comparison of intensity modulated radiation therapy and concomitant boost radiotherapy in the 156. Parotid-sparing setting of concurrent chemotherapy for locally advanced oropharyngeal intensity modulated versus conventional radiotherapy in head and neck carcinoma. Intensity-modulated radiation therapy for the treatment of oropharyngeal carcinoma: the 157. Int J Radiat Oncol outcome in oropharynx cancer with intensity-modulated radiotherapy? Evidence behind use of following intensity-modulated radiation therapy for small primary intensity-modulated radiotherapy: a systematic review of comparative oropharyngeal carcinoma. Treatment of oral cavity intensity-modulated radiation therapy in the postoperative setting. Am J squamous cell carcinoma with adjuvant or definitive intensity-modulated Clin Oncol 2010;33:599-603. Outcome and postoperative intensity-modulated radiotherapy for head and neck patterns of failure after postoperative intensity modulated radiotherapy cancer. Available at: for locally advanced or high-risk oral cavity squamous cell carcinoma. Int J Radiat tumors treated with adjuvant intensity-modulated radiotherapy with or Oncol Biol Phys 2004;59:28-42. Prophylactic radiotherapy for the palliation of advanced head and neck cancer in percutaneous endoscopic gastrostomy tube placement in treatment of patients unsuitable for curative treatment-"Hypo Trial". Radiother Oncol head and neck cancer: a comprehensive review and call for evidence 2007;85:456-462. More than 10% study of palliative radiotherapy for incurable head and neck cancer. The place of interstitial therapy using 192 iridium in the management of carcinoma of the lip. Long-term incidence of hypothyroidism after radiotherapy in patients with head-and-neck 184. Incidence of hypothyroidism following multimodality treatment for advanced squamous cell cancer of 185. A systematic review of interventions for eating and drinking problems following treatment for 186. Swallowing dysfunction in function relationships in parotid salivary glands following conformal and head and neck cancer patients treated by radiotherapy: review and intensity-modulated irradiation of head and neck cancer. Int J Radiat recommendations of the supportive task group of the Italian Association Oncol Biol Phys 1999;45:577-587. Computerized monitoring relationships for the submandibular salivary glands and implications for of patient-reported speech and swallowing problems in head and neck their sparing by intensity modulated radiotherapy. A systematic review of head and neck cancer patient treated with radiation therapy. J Mich salivary gland hypofunction and xerostomia induced by cancer Dent Assoc 2011;93:28-37. Correlation of osteoradionecrosis of the mandible after intensity-modulated osteoradionecrosis and dental events with dosimetric parameters in radiotherapy for head and neck cancer: likely contributions of both intensity-modulated radiation therapy for head-and-neck cancer.

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Lactate concentrations are elevated early after carbon dioxide tension seems to buy 80 mg telmisartan free shipping pulse pressure 83 be preserved order telmisartan 20mg online hypertension quality measures. Cerebrovascular resistance may be elevated for at least 24 h this limits the usefulness of a single measurement dur in comatose survivors of cardiac arrest discount telmisartan 40mg line hypertension zinc. In these patients it may be necessary to buy 40mg telmisartan amex blood pressure 150100 use tidal available evidence, reasonable goals for post-cardiac arrest volumes higher than 6 mL kg? There is no evidence to suggest that one cardiac output monitor is being used, therapy can be further strategy is signi? It is cardiac arrest setting that has been shown to increase feasible to initiate cooling before coronary angiography, and survival rates. The incidence of these causes is potentially higher for also be used either alone or in combination with the above in-hospital cardiac arrest. In the maintenance phase, effective temperature tion of a forced air warming blanket reduces shivering during monitoring is needed to avoid signi? This is best achieved with external or If therapeutic hypothermia is not feasible or con internal cooling devices that include continuous tem traindicated, then, at a minimum, pyrexia must be perature feedback to achieve a target temperature. In summary, both preclinical and clinical evidence Intravascular cooling catheters are internal cooling devices strongly support mild therapeutic hypothermia as an which are usually inserted into a femoral or subcla effective therapy for the post-cardiac arrest syndrome. Although data sup time consuming for nursing staff, result in greater tem port cooling to 32?34? The optimal rate of rewarming is not known, but current concensus is to initiate cooling as soon as possi current consensus is to rewarm at about 0. Shivering should be treated Therapeutic hypothermia is associated with several by ensuring adequate sedation or neuromuscular blockade complications. If therapeutic hypothermia is not under a diuresis and coexisting hypovolaemia will compound taken, pyrexia during the? Diuresis may produce electrolyte should be treated aggressively with antipyretics or active abnormalities including hypophosphatemia, hypokalaemia, cooling. Hypothermia decreases insulin sensitivity and insulin If patients do not show adequate signs of awakening within secretion, which results in hyperglycaemia. Effects already achieved), mechanical ventilation, and sedation on platelet and clotting function account for impaired coag will be required. Hypothermia can impair the consumption, which is further reduced with therapeutic immune system and increase infection rates. Use of published sedation scales for monitor study, pneumonia was more common in the cooled group but ing these patients. The clearance of sedative drugs and neuromuscu During therapeutic hypothermia, optimal sedation can pre lar blockers is reduced by up to 30% at a temperature of vent shivering, and achieve target temperature earlier. Because of the relatively high vasodilator, and therefore increases cooling rates. Recent studies indicate that post-cardiac arrest will require sedation for mechanical ventilation and ther patients may be treated optimally with a target range apeutic hypothermia. Use of sedation scales for monitoring for blood glucose concentration of up to 8 mmol L? No studies directly address the use of further but instead may expose patients to the poten prophylactic anticonvulsant drugs after cardiac arrest in 223 tially harmful effects of hypoglycaemia. Anticonvulsants such as thiopental, and especially 213?215 hypoglycaemia in another recent study of intensive insulin phenytoin, are neuroprotective in animal models, but 226 therapy exceeded 18%, and some have cautioned against a clinical trial of thiopental after cardiac arrest showed no 227,228 216 its routine use in the critically ill. Clonazepam is the most 13,223 sured frequently, especially when insulin is started and effective antimyoclonic drug, but sodium valproate and lev 83 during cooling and rewarming periods. Clonazepam is the drug sants, growth factors, protease inhibitors, magnesium, and of choice for the treatment of myoclonus. The use of low-dose steroids, even in septic shock, for which they are commonly 238 Long-term management given, remains controversial. In a recent study of comatose survivors of out-of are successfully resuscitated have impaired consciousness, hospital cardiac arrest, 5 of 72 (7%) received haemodialysis, and some remain in a vegetative state. The need for pro and the incidence was the same with or without the use 14 tracted high-intensity care of neurologically devastated of therapeutic hypothermia. In another study, renal func survivors presents an immense burden to healthcare sys tion was impaired transiently in out-of-hospital post-cardiac 251,252 tems, patients families, and society in general. To arrest patients treated with therapeutic hypothermia, limit this burden, clinical factors and diagnostic tests are required no interventions, and returned to normal by 28 239 used to prognosticate functional outcome. The indications for starting renal replacement ther tion of care or withdrawal of life-sustaining therapies as a apy in comatose cardiac arrest survivors are the same as 240 likely outcome of prognostication, studies have focused on those used for critically ill patients in general. A recent study showed that prognostication based on neurological examination and diagnostic modalities in? Although several studies Recently several systematic reviews evaluated predictors have shown no statistical difference in complication rates of poor outcome, including clinical circumstances of cardiac between patients with out-of-hospital cardiac arrest who arrest and resuscitation, patient characteristics, neurolog are treated with hypothermia and those who remain nor ical examination, electrophysiological studies, biochemical mothermic, these studies are generally underpowered to markers, and neuroimaging. Most importantly, tant complication in comatose post-cardiac arrest patients, the impact of therapeutic hypothermia on the overall accu occurring in up to 50% of patients after out-of-hospital car racy of clinical prognostication has undergone only limited diac arrest. Having been the most studied factor with widest applicability even in insti tutions with limited technologies and expertise, the primary Placement of implantable focus is on neurological examination, with the use of adjunc cardioverter-de? Detection of asynchrony is important because stim ciated with decreased survival after resuscitation,257?259 but Post-cardiac arrest syndrome 365 at least one study suggested that advanced age did not pre because of the extensive brain injury involving the upper dict poor neurological outcome in survivors. Use of the Many factors during the resuscitation process have been bedside neurological examination can also be compromised associated with functional outcome, but no single factor by complications such as seizures and myoclonus, which, has been identi? Some associa if prolonged and repetitive, may carry their own grave tion with poor functional outcome has been made between 285 prognosis. Some of the best predictors of neurological asystole as the initial cardiac rhythm and noncardiac 260,282 outcome are cranial nerve? Electroencephalography has been extensively studied as at key times after resuscitation. Functional neuroimaging a tool for evaluating the depth of coma and extent of has been used successfully to characterise injury in other damage after cardiac arrest.